Provider Demographics
NPI:1073657169
Name:LIGHTHOUSE HOME HEALTH CARE INC.
Entity Type:Organization
Organization Name:LIGHTHOUSE HOME HEALTH CARE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:FASSOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-466-9199
Mailing Address - Street 1:1805 S 25TH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34947-4752
Mailing Address - Country:US
Mailing Address - Phone:772-466-9199
Mailing Address - Fax:
Practice Address - Street 1:1805 S 25TH ST STE 1
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34947-4752
Practice Address - Country:US
Practice Address - Phone:772-466-9199
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLNR30211217251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL691195196Medicaid